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SCUTHCLD VIASTEIMTER DI SPI SAL PERM T
CCNSTRUCTI CN CR ALTERATI CN PERM T
SEPTI C TANK or CESSPCCL
Per m t Iib. 4154 R Resi dent i al X Non-Iesi dent i al
Fee $ 10. 00 Septic X Cesspool
PERM T I SSLED TO
Narre : JCE STADLER
Address 1: P O BCS( 1439
City St Zip SCUTHCLD NY 11971
Cescr i pt on of Pr oposed Const r uct i on or Al t er at i on
ATI TI CN TO EXI STI N3 SYSTEM
APPR)iED AS SU3M TEED IVPJ NTAI N RECD FED SETBACKS FROM ADJACENT
VELLS, BU La NGS, PROPERTY LI NES AND MATER BC]I ES.
EXCAVATI CN I NSPECTI CN FEW FED
Nbrr a a Owner I NTERNCLAL I NC.
Mei I i ng Address 1 P 0 BCS( 1173
C t y St Zip SCUTHCLD NY 11971
Property Address 1 54800 NAI N RYD
C t y St Zip SCUTHCLD NY 11971
Tax Map Nb. section 64. 00 bl ock 1 I of 1. 600
Cross Street YCUVGS AVENLE
Bui I di ng Feral t N.inber Cr oss Ref er ence:
I ssue Cat e: 9/28/ 13 El i zabet h A Nevi I I e
Sout hold Tow, C er k
(TO/ l SEAL)
TO: Southold Town Building Department
FROM: Carol Hydell, Southold Town Clerk's Office
DATED: September 3, 2013
Transmitted herewith is a copy of application No. 4154 for a Cesspool/Septic Tank ALTERATION
Permit submitted by:
Joe Stadler, for Internodal Inc.
Please review the application and location map and advise if the project has received Suffolk County
Health Department approval and if this office may issue the permit.
Please complete the form below and return it to me. Thank you
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments: Maintain required setbacks from adjacent wells, buildings,property lines and water
Bodies. EXCAVATION INSPECTION REQUIRED.
Signature
Dated
ELIZABETH A. NEVILLE a�`Z` OGS Town Hall,63096 Main Rota.
TOWN CLERK ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ; W fi Southold, New York 11971
MARRIAGE OFFICER 1Fax(631) 765-6145
.0
RECORDS MANAGEMENT OFFICER ";y �i�� Telephone(631)785-1800
FREEDOM OF INFORMATION OFFICER '-70� 4 �` ,�� southoldtown.northfork.nel
....ai
HpLD OFFICE OF THE TOWN CLERK M
TONIN QF E°ARTMENT TOWN OF SOUTHOLD
iN�' O.
BVtLD POja,N•Y,i9g71SOUTHOLD WASTEWATER DISTRICT
SouthO
APPLICATION
CO1FRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 (i) or Non-Residential @$25 Application No. 9 15(f
Permit No.
Applicant Name SOF- .l r-- R
Applicant Mailing Address 17D 1 ')
Sp o. t 1,7
Septic Tank or Cesspool •
Brief Description of Proposed Construction or Alteration (' L&.. P Q. l.5`1-wt,3
Location of Proposed Construction/Alteration:
Owner of Property: 7,-ALc_._.
Owner Mailing Address: Y 0 VaC L173
3ift)1�D ltg7i
Owner Property Address: 5 Li- DO 1 .
301/3 .) )4Y t v)-7
Name and phone number of contact person (,3 ( 715 PD�7
Tax Map No: Section CD 1 , Block f Lot /
Cross Street AVE.
NOTE: LOCATIO MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY Y H HEALTH DEPARTMENT APPR I VAL-
Signa ' ; .plicant •ate
Received by:
v
MAIN ROAD (N. Y.S. Rte. 25 )
N. 72'30'00' E. 92.50'
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ROBERT L. GAMMON AND p 15.9' 7.7. 7.4..t v' •.
AMY A. GAMMON air S. 72'249'30" 1 W. es. s•' =
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WARREN L. SMITH
AND HELEN M SMTH
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CIe 'I1ir' 631.467-6447
ENVIRONMENTAL Fax: 631-467-6621
Antall . ! .�i1�•/ •
•• � MECHANIC HELPER E
tett,rob.. Ora PM. � 1/' /
JOB NAME '__I Ir f pPO
" ply, ‘Q c-•- JOB 411 -- ` r -- 767-1-
ADDRESS n Q„/�T•. , � -"'" V�,�.,J ❑LATE NIGHT
0 SUNDAY
CITY '1, 4 - k\R`4 p HOLIDAY
BILL 1O 1 �`*� T PHONE
ADDRESS 0 NEW
ors EFERRAL
J PEAT
❑ PUMPING
❑ CHEMICALS
aril 4.1"‘t ~ r u Z pec- ,k")...1
❑ AERATION
❑ UNE CLEANING C). 1 `0 ,k,(L kl(Q,,, FEET - -
❑ LOCKING -4Off\ CIC) % _acuyiK rlf
o SERVICE CALL 4\( isri • r t. j,19r L 'c. - +a.,,_.. it,
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C;=.-IA % (6 A e A: ' n}
❑ DIGGINGf
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❑ STACK PIPE ;S Ai i! ncorlit.t..)ocav, roite:
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A t� 4� � C^e ti{t t . C1 - ` 4"), .11}�
o OTHER -cr �4' p ReS a + \4¢i) i ` s"+ r
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—40✓ o.. r.?-0 r ` --- - -11. --t
l tit / J l l' I Q cs '`t'' , j
-� 1'1�s,.:�.ten�,-�-�- �.;,1 SUB TOTAL 45S � O�
ESTIMATE GIVEN Bi FORE WORK. o NO TAX a c c
DO YOU AGREE ALL WAS IN WORKING ORDER
AFTER WORK WAS COMPLETED? 1�s C 0 NO TOTAL i i L
comments: 'd' 46
til c 1181 nd ry 6t 0! C DATE PAID o
GOO . 4ty .. CHECK NO. li-w_T
This Company will not be responsible for any cesspool that could collapse during or after AMT. RECDi.Z>tir
work performed. 0 CASH 0 M.C. 0 VISA 0 LEFT SILL
$60.00 Return Check Fee Applies.
Purchaser shall provide access to job site.It shall be the obligation of the purchaser to inform the Service Company of any above or below ground or
hidden perils.The seller shall not be responsible for damage above or below ground or hidden perils.The Seller shall not be responsible for damage
above or below ground to property or hidden perils.Signor assumes liability representatively and personally for payment of contract amount.
Collection costs.Unpaid balances will accrue interest at the rale of 1B%per yeas I agree b pay interest at the above rade on any uncollected balance and I
agree
to pay the cost of collection of any unpaid balance inckding,but not Waited to,court costs,disbursement and attorney's fees of five hundred dollars
(4500AQ)•
,_ - GENERATOR SIGNED STATEMENT
I, f - ,hereby affirm that I am the owner:or use;of the individual Sewage Disposal Facility(septic
tank/leaching hies)located at the address of the invoice and:(1).That the facilities to be pumped contain only sanitary sewage;(2).That I have
not been notified by the Suffolk County Department of Health or the Nassau County Department of Health to have this system pumped by a licensed
industrial haute;That neither I nor any person in my family or in my employ have added any chemical solvent waste or industrial wastes of any kind
to the facility to be pumped and that I make this statement knowing that the waste or individual wastes of any kind to the facility b be pumped and
that i amts this Statement knowing that the waste will be disposed of at a Municipal Septage Treatment Facially and that in the event that any chemi-
cal solvent waste or industrial waste of any kind have been added,legal action may be undertaken by the appropriate regulatory agency against any
or all parties involved.
I,herby affirm under penalty of perjury that information provided on this form is true to the best of,my knowledge bjelief. False statements made
wain ase nt nithahIe Aa A eIMea A mi damaanna nfmmn Ow to marti91f1AA of o P nd I awl'', ,,